|Year : 2021 | Volume
| Issue : 3 | Page : 316-322
|Oral health indicators of oral health related quality of life among Indian elderly: A cross-sectional study
Charu Mohan Marya1, Harpreet Singh Grover2, Shourya Tandon3, Anil Gupta4, Ruchi Nagpal1, Pratibha Taneja1
1 Department of Public Health Dentistry, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India
2 Department of Periodontology, SGT, Gurugram, Haryana, India
3 Department of Public Health Dentistry, SGT, Gurugram, Haryana, India
4 Department of Pedodontics, SGT, Gurugram, Haryana, India
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|Date of Submission||28-Jan-2019|
|Date of Decision||27-Oct-2020|
|Date of Acceptance||16-Dec-2021|
|Date of Web Publication||23-Feb-2022|
| Abstract|| |
Aim: To assess the impact of tooth loss and periodontal status on oral health related quality of life among Indian elderly. Methodology: This study was a cross-sectional study conducted among 1200 elderly subjects of Faridabad district of Haryana. Study subjects were selected by a combination of systematic, cluster and multistage sampling techniques. The data were collected through a clinical oral examination for tooth loss and periodontal status assessment (WHO Oral Health Survey 2013) and a self-administered questionnaire to assess the OHRQoL. Dental behaviours such as dental visiting patterns, tobacco chewing habits and oral hygiene practices were also recorded. Results: In bivariate analysis significant associations were found among age, gender, education, tooth mobility and Oral health related quality of life (OHRQoL). Multivariate logistic regression showed significant impact of number of missing teeth and mobility on OHRQoL (P < 0.05). Conclusion: The conclusions derived from this study are of considerable importance for Indian policy makers in their work with planning and implementing public oral health strategies for geriatric population.
Keywords: ADD-GOHAI, oral health related quality of life, periodontal status, SC-GOHAI, tooth loss
|How to cite this article:|
Marya CM, Grover HS, Tandon S, Gupta A, Nagpal R, Taneja P. Oral health indicators of oral health related quality of life among Indian elderly: A cross-sectional study. Indian J Dent Res 2021;32:316-22
|How to cite this URL:|
Marya CM, Grover HS, Tandon S, Gupta A, Nagpal R, Taneja P. Oral health indicators of oral health related quality of life among Indian elderly: A cross-sectional study. Indian J Dent Res [serial online] 2021 [cited 2022 Jun 26];32:316-22. Available from: https://www.ijdr.in/text.asp?2021/32/3/316/338132
| Introduction|| |
Oral health-related quality of life may be defined as a “self-report specifically pertaining to oral health – capturing both the functional, social and psychological impacts of oral disease.” Oral health is a dynamic subjective concept which is influenced by an array of factors.
The concept of OHRQoL can be used for various purposes, including evaluation of people's needs and their levels of satisfaction, evaluation of the results of intervention and human services programs, the planning and provision of these services, and the formulation of appropriate policies for the general population and specific sub-populations.
The measurement of oral health is historically derived from the disease based model and oral diseases were measured with objective and quantitative indicators. Thus, the prevalence of oral diseases has been described in various samples of adults but less is known about how the diseases and symptoms affect geriatrics daily activities and quality of life. The use of only clinical indicators for oral health status and treatment-needs evaluation is recognized to have serious limitations. There are several instruments for measuring the oral health-related quality of life but most frequently used are Oral Health Impact Profile (OHIP), Oral Impact on Daily Performances (OIDP), and Geriatric/General Oral Health Assessment Index (GOHAI) etc.
GOHAI is a 12-item measure originally developed for use with older adult populations, although more recently it has been used with populations of younger adults. It measures patient reported oral functional problems and also assesses the psychosocial impacts associated with oral disease. The GOHAI is fairly compact & it has been validated and widely used in North-America with proven reliability.
The elderly represent a special category in the population, not only because of the consequences of specific disease and conditions but also because they often have restricted access to medical care, including dental care. In most of the gerontological literature, people above 60 years of age are considered as 'old' and constituting the 'elderly' segment of the population. The group can also experience certain restrictions due to the condition of their teeth or dentures that modify their life styles and social interactions, thus affecting their oral health related quality of life. They must be acknowledged as integral members of the society and must have the right to enjoy a good quality of life and full equity in access to services necessary for optimal health.
Dental disease affects a large number of people and cause much discomfort and pain. Their impact is therefore considered dental caries. Tooth loss and periodontal disease are most common oral diseases affecting 50%–60% and 95%–100% adult population in India respectively. Nearly 19% of the population aged between 65 and 74 years is edentulous. India is the second highest populated country with the population of 1,210,854,977. Out of which 8% of the population is above 60 years. As the life expectancy is increasing, estimated percentage of geriatric population in upcoming years is also increasing i.e., 8.2% in year 2020 and 20% in the year 2050.
There are several challenges being faced in delivery of oral health care to the elderly population, such as lack of man power and poor accessibility which is compounded by poverty and illiteracy. Moreover there is no data pertaining to oral health related quality of life of elderly population of India which is essential for planning oral health services for the population. Thus in the light of above situation, it is essential to assess the oral health related quality of life, among elderly population and hence this study was conducted. As there is paucity of documented literature regarding effect of various oral diseases on oral health related quality of life of elderly population in India hence this study was conducted with an aim to assess the impact of tooth loss and periodontal status on OHRQoL among elderly population residing in Faridabad.
| Methodology|| |
This study was a cross-sectional study conducted among 1200 elderly subjects of Faridabad district of Haryana.
The study population was selected from the elderly subjects (60 years and above) of Faridabad city. Ethical clearance was obtained from the Ethical committee number (SGT/FDS/540) 'Shri Guru Gobind Singh Tricentenary University'-Gurgaon after explaining the aim, importance and methodology of the study. Information sheet was provided to the each subject explaining the purpose and procedure of the study, before taking informed consent from them prior to the examination.
Elderly people currently residing in Faridabad city for at least past one year and who were willing to give informed consent were included in the study. Physically challenged and mentally compromised elderly people and those with cognitive or terminal illness were excluded.
Sample size determination
The sample size is estimated by using nMaster software (2.1 version, CMC, Vellore). Sample size of 1200 adults was determined following pilot study on 66 subjects. Study subjects were selected by a combination of systematic, cluster & multistage sampling techniques.
Stage 1: Selection of Primary Sampling Units (PSU's) - Ward
The primary sampling unit for this survey was ward. In total, there are 35 wards within Municipal Corporation of Faridabad. To determine the number of PSUs to be selected, a 'sample take' value was considered. The 'sample take' is the number of subjects enrolled for the study in each PSU. It was pre-decided that 100 elderly were included from each ward of Faridabad. By dividing the total sample size i.e., 1200 by the 'sample take' i.e., 100 at Ward level (PSUs); the number of required PSUs in the Faridabad area was arrived at 12. From a list of all PSUs (35 Wards), 12 wards were selected by random systematic sampling. For this, a number was selected from 1 & 2 and then every third ward was selected for inclusion in the study. In this way, a total of 12 wards were selected from the list of 35 wards in Faridabad.
Stage 2: Selection of Secondary Sampling Units (SSU's) – Areas
Areas coming under the selected wards formed the Secondary Sampling Units (SSUs). Two areas were randomly selected from each of the selected ward with equal probability by lottery method. It was also predecided that from each area of selected ward, 50 subjects were included. If in a ward, a sample size of 100 could not be achieved in 2 areas, then a third area was further randomly chosen to achieve the required number.
Stage 3: Selection of Tertiary Sampling Units (TSU's) – Households
Within the SSUs, Households formed the Tertiary Sampling Units (TSUs). The investigator found a fixed location within the boundaries of the selected area (such as a school or temple)) and (following the left hand rule) proceed to the starting household i.e., 5th house from the fixed starting point. A household in this survey was defined a unit of people who share the same 'kitchen' as opposed to people who share the same roof. All the elderly persons of that household were enrolled for the study. After completing the interview and clinical examination, 4 households would be skipped (using the left hand rule) thereby calling on the 5th household. Selecting the household one by one was continued till the prescribed number was achieved i.e., 50 elderly adults from that area. In situations like, absence of elderly subjects in the selected household, refusal for undergoing interview/clinical examination, next 5th house was selected [Figure 1].
Development of survey instrument:
Oral health related quality of life was measured in rural elderly subjects of Faridabad by using Hindi version of Geriatric Oral Health Assessment Index (GOHAI). The original GOHAI, a 12 item questionnaire, was developed by Atchinson and Dolan in 1990 and used on North American elderly people and it showed satisfactory internal consistency and proper validity.
The GOHAI was translated into Hindi by three dentists who were fluent in both English and Hindi and then the Hindi version was back-translated into English by another three dentists who were again fluent in both English and Hindi. This translated version was compared with the original version and the items were worded in a similar manner with comparable meanings. This Hindi version of GOHAI was tested for its reliability and validity in a pilot study.
The data collection will include a combination of questionnaire administration and clinical examination for the assessment of severity of periodontal condition and tooth loss.
The data collected came from a clinical oral examination and a self-administered questionnaire. Apart from the GOHAI questions, information regarding socio-demographic data such as age, sex, educational level, marital status, occupation and income were collected. Dental behaviours such as dental visiting patterns, tobacco chewing habits and oral hygiene practices were also recorded. Questions regarding self-perception of oral health, oral health and perceived need for dental treatment were also put forward. Those respondents, who were unable to fill the questionnaire themselves, were helped by the examiner.
For each of the 12 items of GOHAI-Hi questionnaire, participants can respond to experience in the last 3 months on a Likert-type scale (1 = never; 2 = seldom; 3 = sometimes; 4 = often; 5 = always). Two different scores of the GOHAI was calculated (Hassel AJ et al., 2008). The final score for each participant ranged from 12 to 60 points, with higher scores denoting better self-rated oral health or a lower degree of negative impact on quality of life. The final GOHAI score of each individual was categorized as good (57–60), moderate (51–56) or poor (<50), indicating a low, moderate, and high degree of impact on quality of life, respectively.
The clinical examination was performed at the same time after the participants were interviewed. A full mouth oral examination of all the subjects was performed by a single trained, calibrated dentist using sterilized instruments.
Periodontal status, loss of attachment, dentition status and prosthetic status was assessed using WHO criteria, 2013. Tooth mobility was assessed using modified Miller's index (Laster et al., 1975) [Table 1]. Prior training and calibration of the examiner and training of the recording assistant was done. The intra-examiner variability (kappa value) ranged from 0.82-0.86 for all the observations.
The data was analysed using SPSS 21.0 (Statistical Package for Social Sciences) package for relevant statistical comparisons. Student's t-test was used for comparing two groups and one way ANOVA when comparing more than two groups on continuous, normally distributed variables. Multivariate logistic regression was carried out for predictive analysis of impact of variables on OHRQoL. Chi-square test was used for categorical variables. A value of P < 0.05 was considered statistically significant.
| Results|| |
A total of 1200 elderly subjects were included in the study. Majority of the study population were found to be in the age group of 70-79 years and were males [Table 2].
[Table 3] shows the participants' responses to the GOHAI items, and the values of mean GOHAI score and standard deviation. The most commonly used response in the GOHAI was 'sometimes' or 'often'. It also shows mean GOHAI score for each item ranged from 2.05 ± 1.56 to 4.72 ± 0.80
- 88.3% of the study subjects were able to swallow comfortably
- 65.1% were able to eat without discomfort
- 39.7% subjects were pleased with the look of their teeth.
Simple GOHAI scores were obtained by counting the number of items with responses sometimes/often/always. GOHAI items showing the maximum impacts were reported as follows [Table 3]:
- 81.3% subjects faced discomfort while eating
- 69% subjects used medication to relieve pain
- 63.3% had trouble biting or chewing food.
Mobile teeth and Type of tobacco use presented to be the significant predictors of OHRQoL [Table 4]. As [Table 5] shows, variables significantly related to moderate OHRQoL status, respectively, were “missing teeth and proportion of teeth among which mobility were present i.e., moderate OHRQoL was significantly better among subjects with less number of missing tooth or mobility. Rest all the variables failed to show significant relationship with good and moderate OHRQoL (P > 0.05).
|Table 4: Bivariate analysis showing the relationship between different variables and determinants with OHRQoL|
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|Table 5: Multivariate logistic regression for association of OHRQoL with different clinical predictors|
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| Discussion|| |
In this study, four indicators of periodontal diseases were considered; proportion of mobile teeth, bleeding scores, pockets and Loss of Attachment (LOA) scores. A statistical significant association was found between proportion of mobile teeth and mean- ADD-GOHAI and SC-GOHAI scores. Though few studies have focused on tooth mobility and its impact on quality of life, study conducted by Wan-Nasir et al. has depicted similar relationship. This could be explained by the fact that mobile teeth not only causes pain and discomfort but also interferes with the oral functions thus affecting the oral health related quality of life negatively. No significant association was found between loss of attachment, periodontal pocket and bleeding with ADD-GOHAI and SC-GOHAI scores. This component of the study could not be compared with other study due to paucity of documented literature. In 2003, WHO, the World Dental Federation and the International Association for Dental Research appointed a commission that would propose overall goals for oral health by 2020, as guidelines for health services. Maintenance of at least 21 teeth was selected by the study group as the condition for functional dentition. Hence, there is an interest in evaluating the extent of tooth loss among elderly individuals in this manner. In this study concept of shortened dental arch was utilized i.e., there should be at least minimum of 20 teeth present in the oral cavity. Subjects who were having less than 20 missing teeth were having better OHRQoL than those having more than 20 missing teeth though this association failed to reach the level of statistical significance.
No statistical significant difference was observed in mean GOHAI scores of subjects with different prosthetic status. This is in agreement with some studies conducted in different parts of the world. This finding does not match other studies conducted by Hassel et al., Naito et al., Zainab et al. Reason for this could be that very less number of subjects was wearing partial or complete dentures in this elderly population indicating high unmet prosthetic needs.
Oral health related quality of life in terms of GOHAI scores: The mean value for the ADD-GOHAI scores for the entire population in this study was 40.87 ± 8.44 and mean value for SC-GOHAI in the study population was found to be 7.26 ± 3.75. In qualitative terms elderly subjects gave a favourable assessment of their oral health related quality of life. This is consistent with few studies (Nunes CI & Abegg C) that evaluated different measurements of quality of life related to oral health and concluded that elderly individuals assessed their oral health favourably even when the clinical condition was unsatisfactory.
When percentage distribution of the elderly subjects according to their responses to the individual questions in GOHAI was compared with the study conducted by Atchison and Dolan it was found that the subjects reported more problems in physical functioning followed by pain/discomfort and fewer problems in psychosocial functioning. This could be attributed to the fact that Indian elderly might have a higher acceptance of their oral conditions than would respondents from a western culture such that oral problems would not disturb the psychosocial domain of oral health related quality of life, thus, they reported fewer problems in psychosocial functioning. This group of elderly population does not regard oral conditions as barriers to social interactions. That is why, for the psychosocial items i.e., item 6 (“limits contact with people”), item 10 (“self-conscious of teeth problems”) and item 11 (“uncomfortable eating in front of others”), the majority answered either “never” or “seldom”. This is in accordance with the similar study conducted in Malaysian elderly. 119 Apart from this, for the pain/discomfort item 8 “used medication to relieve pain”, majority responded either “never” or “seldom”. This could be due to relative unavailability of oral health care in rural areas.
Item response distributions showed that this group of elderly population tended towards the terms of never, seldom, sometimes and often. In eight items, very few respondents answered “always”. The possible explanation is that term “always” is very strictly restricted to “not a moment without problem” which could hardly be applied to some of the items over a 3-month period. Despite the importance of the results of this study, its cross-sectional design, which does not allow the identification of causal associations, limits the investigation. Thus, evidence from longitudinal studies is needed to determine such associations.
| Conclusion|| |
This thesis provides an insight upon the oral health related quality of life of elderly population of Faridabad. The conclusions derived from this study are of considerable importance for Indian policy makers in their work with planning and implementing public oral health strategies for geriatric population.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Charu Mohan Marya
986, Sector 15, Faridabad, Haryana
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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